1 / 56

Communicable Disease Update

Communicable Disease Update. Matt Zahn, MD Medical Director Epidemiology Orange County Health Care Agency August 14, 2013. As of August 1, 2013, 158 confirmed cases

lark
Download Presentation

Communicable Disease Update

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Communicable Disease Update • Matt Zahn, MD • Medical Director • Epidemiology • Orange County Health Care Agency • August 14, 2013

  2. As of August 1, 2013, 158 confirmed cases 9 states affected: Arizona (23), California (77), Colorado (28), Hawaii (8), New Mexico (9), Nevada (6), Utah (3), and Wisconsin (2), New Hampshire 10 cases in Orange County All ill people who reported eating this product purchased it from Costco markets Product was also sold at Harris Teeter stores No cases associated with these stores thus far Hepatitis A Outbreak and Townsend Frozen Berry Blend

  3. 55% are women Ages range 1 – 84 years; 57% between 40 – 64 years of age. 11 children age 18 ill None were previously vaccinated. Illness onset dates range from 3/31/2013 – 7/14/2013 69 (44%) hospitalized No deaths Epidemiology of Those Ill

  4. Hepatitis A in Children • 30% of children under 6 are symptomatic • These children are still infectious! • Children can be the source of outbreaks • Older children and adults have symptoms 70% of the time • Rate of disease low because of asymptomatic children, but also high immunization rates

  5. Vehicle for hepatitis A appears to be a common shipment of pomegranate seeds from Goknur Foodstuffs Import Export Trading in Turkey Viral genotype is 1B FDA will detain shipments of pomegranate seeds from Goknur These pomegranate seeds are used in: Townsend Farms brand Organic Antioxidant Blend sold by Costco stores Organic Antioxidant Berry Blend sold by Harris Teeter Woodstock Frozen Organic Pomegranate Kernels from Scenic Food Company All products recalled FDA and CDC Investigation

  6. Prophylaxis recommended for exposure within last two weeks Considered for all persons who consumed product Single-antigen Hepatitis A Vaccine is recommended California Department of Public Health Post Exposure Prophylaxis Recommendations

  7. The following are at increased risk of severe HAV infection or may have a decreased immune response to vaccine: Persons with chronic liver disease (e.g., cirrhosis) Immunocompromised persons, including persons: With HIV/AIDS; Undergoing hemodialysis; Have received solid organ, bone marrow or stem cell transplants; Receive high dose steroids (>2mg/kg/day), chemotherapy, or immunomodulators and/or biologic medications Vaccine may be given in addition to IG to potentially provide longer-term protection, but vaccine response may be limited. People who should receive IG for PEP

  8. Provide education and advice Vaccinate or give immune globulin to persons who have consumed the product within the last two weeks Environmental Health assured product is pulled from local stores Work with Costco to assure that accurate message is disseminated Follow up on cases, including prophylaxis for their close contacts HCA Response

  9. On March 30, 2013, three patients in China with fatal cases of rapid, progressive pneumonia were confirmed to be infected with influenza A H7N9 Virus had not been detected in humans or animals previously Avian Influenza A (H7N9)

  10. Geographical Location Confirmed human cases of avian influenza A(H7N9) reported to WHO

  11. Epidemiological Curve of Confirmed Cases of Avian Influenza A(H7N9) Reported to WHO, by Day, 2013 N= 122 confirmed cases for whom date of onset is known Mar Apr May Feb Date of Onset

  12. As of May 30, 2013: WHO reported 132 laboratory-confirmed cases 43 deaths Most patients had severe respiratory illness Some mild illness in human cases was seen Avian Influenza A (H7N9)

  13. Influenza A Nat Struc & Mol Bio 16, 233 - 234 (2009) Ppdictionary.com

  14. Antigenic Drift • Point mutations in HA or NA • Generally results in relatively small changes in virus www.influenzacentre.org

  15. Antigenic Shift • Reassortment of gene segments • Leads to novel and potentially pandemic strains www.influenzacentre.org

  16. All 16 HA and all 9 NA subtypes of influenza A virus are detected in wild water birds H17N10 is found in bats Most infections are mild or asymptomatic in avian species Outbreaks in wild birds and poultry have been associated with avian influenza H5 subtypes Outbreaks in poultry have been associated with H7 subtypes Influenza in Avian Populations

  17. Human infections are generally confined to H1, H2, and H3 subtypes These subtypes have affinity for host cell receptors containing α-2,6-linked sialic acid Direct transmission of influenza from domestic poultry to people found with H5N1, H7N2, H7N3, H7N7, H9N2, and H10N7 subtypes Resulting human infections were generally mild H5N1 subtype notably has caused severe disease Hosts for Influenza A

  18. Virus arose from multiple reassortment events Four or more influenza A viruses appear to have contributed genetically H7 gene is genetically close to sequences isolated from ducks in Zhejiang province N9 gene is similar to genes from H7N9 viruses found in wild ducks in South Korea The six internal genes are similar to H9N2 viruses isolated from poultry and ducks in China Avian Influenza A (H7N9) Origination www.thelancet.com Vol 381 June 1, 2013

  19. H7N9 Characteristics of 111 Patients • Characteristic Number (%) • Median age, years 61(3-88) • ≥65 yo 47(42.3) • ≤14 yo 2 (1.8) • Male 92 (65) • Preexisting Condition 68 (61) • Hypertension 51 (45.9) • Diabetes 18 (16.2) • Immunosuppression 10 (9.0) • Pregnancy 2 (1.8) • Exp. poultry prev. 14 days 62 (55.9) n engl j med 368;24 nejm.org june 13, 2013

  20. H7N9 Symptoms • Characteristic No. (%) • Fever • Maximal temperature • Fatigue • Conjunctivitis • Cough • Sputum production • Hemoptysis • Shortness of breath • Diarrhea or vomiting 111 (100.0) °C 39.2±0.8 40 (36.0) 0 (0) 100 (90) 62 (55.9) 27 (24.3) 62 (55.9) 15 (13.5) n engl j med 368;24 nejm.org june 13, 2013

  21. H7N9 Complications • Complication No. (%) • Pneumonia 108 (97.3) • Acute respiratory distress 79 (71.2) syndrome • Shock 29 (26.1) • Acute kidney injury 18 (16.2) • Rhabdomyolysis 11 (9.9) n engl j med 368;24 nejm.org june 13, 2013

  22. 109 of 111 hospitalized Antivirals initiated in 108 patients Median of 7 days after the onset of illness 30 (27.0%) died, most from refractory hypoxemia Outcome of H7N9 Infection n engl j med 368;24 nejm.org june 13, 2013

  23. Serology survey of 20,000 Chinese persons with influenza symptoms found only 6 cases of H7N9 Survey of over 3000 contacts of cases found no evidence of disease Mild disease seems to be unusual Minimal human-to-human transmission seems to have occurred No sustained human-to-human transmission has occurred H7N9 and Mild Disease EID Volume 19, Number 8—August 2013

  24. Clinical Illness Criteria Patients with new-onset severe acute respiratory infection requiring hospitalization AND Patients for whom no alternative infectious etiology is identified Exposure Criteria Recent travel (within ≤ 10 days of illness onset) to a country where human cases of H7N9 have been detected OR Recent close contact (within ≤ 10 days of illness onset) with a confirmed case of human infection with H7N9 virus Influenza A H7N9 Testing Criteria:

  25. PCR is test of choice for influenza viruses, including avian influenza A (H7N9) With H7N9, initial PCR testing will indicate: Positive for influenza A Negative for H1pdm09 Negative for H3 Follow up testing for H7N9 will occur at that point OCHCA can facilitate this testing Avian Influenza A (H7N9) Testing

  26. Oseltamivir is recommended for treatment of persons of any age Zanamivir is recommended for children aged 7 and older Recommended duration of treatment for uncomplicated illness is 5 days Longer courses of treatment should be considered for severely ill hospitalized H7N9 patients Optimally treatment begun as soon as possible and within 48 hours of illness starting In severe disease, starting antivirals after 48 hours has still been associated with improved survival Antiviral Treatment Recommendations for Influenza A and B

  27. H7N9 strain was detected from: Chickens Ducks Pigeons Live bird markets Initial human cases found in Zhejiang, China when migratory birds were moving north and transiting at the Yangtze River Delta No increase in poultry deaths occurred H7N9 and Avian Populations

  28. Aggressive follow up on contacts of cases Over 3000 contacts followed for symptoms No additional cases found Closing of bird markets Chinese Health Authority Response AAP

  29. Avian Migratory Patterns

  30. H7N9 infection does not lead to significant illness in birds In contrast to H5N1 Identification and control of viral spread in avian populations will be difficult Recurrence of H7N9 in avian populations is anticipated Avian Influenza A (H7N9)

  31. First identified in 2010 12 cases identified in Indiana in 2013 All with close contact to pigs in fair settings Limited human-to-human spread of this virus has been detected No sustained or community spread of H3N2v has been identified Sporadic infections and even localized outbreaks among people with this virus may continue to occur Influenza A H3N2v

  32. Recommended each year for all persons 6 months of age and older Influenza vaccine for upcoming season will contain: A/California/7/2009 (H1N1)pdm09-like virus A(H3N2) virus like A/Victoria/361/2011b B/Massachusetts/2/2012-like virus And for quadrivalent vaccine: B/Brisbane/60/2008-like virus Influenza Vaccine

  33. Development of influenza A H7N9 vaccine has begun Potential candidate vaccine viruses have been identified H7-derived candidate strains have historically been slow-growing Non-egg based vaccines may provide opportunity for quicker development of vaccine Recombinant DNA vaccine Cell culture based vaccine Influenza A H7N9 Vaccine

  34. Middle Eastern Respiratory SyndromeCoronavirus

  35. Coronaviruses and Human Disease • Five human respiratory coronaviruses have been described: • Causers of colds and URIs • 229E • OC43 • NL63 • Causers of Pneumonia: • HKU1 • SARS

  36. The first laboratory-confirmed case of MERS-CoV: a 60-year-old man from Bisha, the Kingdom of Saudi Arabia, who died of rapidly progressive community-acquired pneumonia and acute renal failure On September 23, 2012, WHO Announces:

  37. MERS-CoV from September, 2012-Present

  38. Multiple clusters of human cases have occurred Healthcare associated events Family clusters Human to human transmission has occurred, though no sustained community transmission MERS CoV Clusters

  39. MERS-CoV Hospital Outbreak, Saudi Arabia Family Member Health Care Worker Case Community Ward 1, Hospital A Ward 2, Hospital A Dialysis, Hospital A ICU, Hospital A Ward, Hospital B Dialysis, Hospital C ICU, Hospital D Ward, Hospital D NEJMoa1306742 4/8 4/15 4/22 5/13 4/29 5/6

  40. MERS-CoV Clusters NEJMoa1306742

  41. Cases of laboratory-confirmed MERS-CoV reported from Saudi Arabia between Sept 1, 2012, and June 15, 2013 46 adults, one child 36 (77%) male 28 (60%) died Case-fatality rate rose with increasing age Two of the 47 cases were previously healthy Review of 47 Patients with MERS-CoV TheLancet.com Published Online 7/26/13

  42. 45 (46%) had underlying comorbid medical disorders No. (%) • Diabetes • Hypertension • Chronic cardiac disease • Chronic renal disease 32 [68%] 16 [34%] 13 [28%] 23 [49%] TheLancet.com Published Online 7/26/13

  43. Fever Cough Shortness of breath Myalgia Diarrhea Vomiting Abdominal pain MERS-CoV Clinical Presentation 46 [98%] 39 [83%] 34 [72%] 15 [32%] 12 [26%] 10 [21%] 8 [17%] TheLancet.com Published Online 7/26/13

  44. Multiple reports of mild disease Initial symptoms may not be respiratory GI illness can be prominent Broader serologic analysis is ongoing MERS-CoV Disease Spectrum

  45. Fast spread of SARS occurred early in the outbreak SARS often spread between healthcare workers and their patients Mainly direct or short-range transmission ‘Superspreaders’ existed who generated a far greater than average number of secondary cases Reasons for this are still not known for certain, likely a combination of host and viral factors SARS-CoV and its Spread

  46. Bats Mice Birds Dogs Pigs Cattle Viruses tend to be specific for individual species, but mutation occurs Coronaviruses infect and cause disease in many animal species:

  47. SARS-CoV thought to have originated in the Himalayan palm civet found in south China MERS-CoV source still uncertain South African bat Neoromicia cf. zuluensis derived CoV is closest phylogenetically to date Intermediate host is considered possible First cases of MERS-CoV associated with camels, sheep, goats exposure Sources of Coronavirus

  48. Human-to-human transmissibility of MERS CoV appears to be low Sustained community transmission has not been seen Close monitoring of health-care workers and household contacts has not revealed large numbers of secondary infections MERS CoV Infectivity

  49. Infectious Period Not clearly established Likely to extend from the onset of fever until 10 days after fever resolves Incubation Period Available data suggest that symptoms have occurred up to 14 days after last exposure. MERS-CoV Epidemiology

  50. A person with an acute respiratory infection, which may include fever (≥ 38°C , 100.4°F) and cough; AND Suspicion of pulmonary parenchymal disease; AND History of travel from the Arabian Peninsula or neighboring countries within 14 days; AND Not already explained by any other infection or etiology MERS-CoV Clinical Case Definition

More Related